NICU PERFORMANCE: MISSED NURSING CARE AND INFANT OUTCOMES More than half of all infant deaths annually in the U.S. are accounted for by infants with very low birth weight (VLBW)(< 1500 grams or 3.3 lbs.), indicating the high mortality burden carried by the over 60,000 infants born with VLBW. One in four VLBW infants dies; nine out of ten of these deaths occur in the first month of life while hospitalized in the neonatal intensive care unit (NICU). There are large unexplained variations in VLBW infant mortality across NICUs that cannot be accounted for by infant risk factors, providing a compelling need to examine factors in the health care system that account for these variations. Since optimal management of VLBW infants depends on skilled nursing care, with the average NICU nurse caring for 2 or 3 infants at a time, we seek to ascertain if missed nursing care accounts for variation in infant mortality, nosocomial infection, length of stay, and parental satisfaction in order to identify points of intervention to improve outcomes. Missed nursing care, defined as required nursing care that is omitted or delayed in response to multiple demands or inadequate resources, occurs in this setting with potentially important consequences on patient outcomes. Therefore there is a critical need to quantify the impact on infants and parents and to identify the factors responsible for missed nursing care. The results of this study will allow for the development of novel, evidence-based, and clinically effective strategies to improve the health and life course of VLBW infants. To determine the effects of missed care on infant outcomes and parent satisfaction and to determine factors associated with missed NICU nursing care, we will first merge four large datasets: 1) the National Database of Nursing Quality Indicators Registered Nurse Survey (NDNQI RN Survey) which includes information on missed care nursing, the nurse work environment and acuity-adjusted NICU nurse workload, 2) the Healthcare Cost and Utility Project State Inpatient Data that provides data on patient outcomes, 3) the American Hospital Association data on hospital structural measures, and 4) the Medicare Cost Report, which provides data on financial margins. Then, we will study parental satisfaction through a survey 240 parents of VLBW infants in 24 NDNQI units linked to the NDNQI RN survey data. With data from 89 NICUs across the nation (representing 5,785 VLBW infants) we will be able to (Aim 1): Determine associations between missed nursing care and NICU patient outcomes for VLBW infants. With the primary parent survey data we will be able to (Aim 2): Determine the association between missed nursing care and parent satisfaction with care in the NICU; and with data from 8,950 RNs employed in 179 NICUs be able to (Aim 3): Identify nurse and NICU organizational factors associated with missed nursing care. This research will result in healthier lives and better parental experiences for high-risk infants treated in the NICU by improving nursing care.